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Jouffroy R, Ecollan P, Chollet-Xemard C, Prunet B, Elie C, Treluyer JM, Vivien B. Evaluation of the effectiveness of potassium chloride in the management of out-of hospital cardiac arrest by refractory ventricular fibrillation: Study protocol of the POTACREH study. PLoS One 2023; 18:e0284429. [PMID: 37043520 PMCID: PMC10096226 DOI: 10.1371/journal.pone.0284429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/10/2022] [Indexed: 04/13/2023] Open
Abstract
PURPOSE Out-of-hospital cardiac arrest (OHCA) has a poor prognosis, with an overall survival rate of about 5% at discharge. Shockable rhythm cardiac arrests (ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) have a better prognosis. In case of shockable rhythm, treatment is based on defibrillation, and thereafter, in case of failure of 3 external electric shocks (EES), on direct intravenous administration of 300 mg amiodarone, or lidocaine when amiodarone is unavailable or inefficient. During surgical procedures under extracorporeal circulation, a high potassium cardioplegia solution is administered to interrupt cardiac activity and facilitate surgical procedure. By extension, direct intravenous administration of potassium chloride (KCl) has been shown to convert VF, resulting in return to a hemodynamically efficient organized heart rate within a few minutes. The aim of this study is to provide clinical evidence that direct intravenous injection of KCl, into a patient presenting with OHCA due to refractory VF although 3 EES, should interrupt this VF and then allow rapid restauration of an organized heart rhythm, and thus return of spontaneous circulation (ROSC). METHODS A multicenter, prospective, single group, phase 2 study will be conducted on 81 patients presenting with refractory VF. After failure of 3 EES, each patient will receive direct intravenous injection of 20 mmol KCl instead of amiodarone. The primary outcome will be survival rate at hospital admission. Major secondary outcomes will include ROSC and time to ROSC in the prehospital setting, number of VF recidivism after KCl injection, survival rate at hospital discharge with a good neurologic prognostic, and survival rate 3 months after hospital discharge with a good neurologic prognostic. RESULTS No patient is currently included in the study. DISCUSSION Conventional guideline strategy based on antiarrhythmic drug administration, i.e. amiodarone or lidocaine, for OHCA due to shockable rhythm, has not yet demonstrated an increase in survival at hospital admission or at hospital discharge. This may be related to the major cardiodepressant effect of those drugs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04316611. Registered on March 2020. AP-HP180577 / N° EUDRACT: 2019-002544-24. Funded by the French Health Ministry. https://clinicaltrials.gov/ct2/show/NCT04316611.
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Affiliation(s)
- Romain Jouffroy
- SAMU de Paris, Service d’Anesthésie-Réanimation, Hôpital Universitaire Necker—Enfants Malades, APHP Centre, Assistance Publique—Hôpitaux de Paris and Université de Paris, Paris, France
| | - Patrick Ecollan
- SMUR Pitié Salpêtrière, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Charlotte Chollet-Xemard
- SAMU du Val de Marne, Hôpitaux Universitaires Henri Mondor, Assistance Publique—Hôpitaux de Paris, Créteil, France
| | | | - Caroline Elie
- URC Cochin, Assistance Publique—Hôpitaux de Paris, Paris, France
| | | | - Benoit Vivien
- SAMU de Paris, Service d’Anesthésie-Réanimation, Hôpital Universitaire Necker—Enfants Malades, APHP Centre, Assistance Publique—Hôpitaux de Paris and Université de Paris, Paris, France
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Romain J, Marie CL, Daniel J, Stéphane T. Bolus intravenous potassium chloride for recurrent ventricular fibrillation. Am J Emerg Med 2023:S0735-6757(23)00073-6. [PMID: 36797168 DOI: 10.1016/j.ajem.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
We report the feasibility and recommend the potential efficacy of a bolus intravenous potassium chloride during out-of-hospital cardiac arrest with recurrent ventricular fibrillation following an acute coronary syndrome in a man in his 40's.
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Affiliation(s)
- Jouffroy Romain
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France.
| | - Couetoux Louis Marie
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France
| | - Jost Daniel
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France
| | - Travers Stéphane
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France
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Brixius SJ, Pooth JS, Haberstroh J, Damjanovic D, Scherer C, Greiner P, Benk C, Beyersdorf F, Trummer G. Beneficial Effects of Adjusted Perfusion and Defibrillation Strategies on Rhythm Control within Controlled Automated Reperfusion of the Whole Body (CARL) for Refractory Out-of-Hospital Cardiac Arrest. J Clin Med 2022; 11:jcm11082111. [PMID: 35456204 PMCID: PMC9031732 DOI: 10.3390/jcm11082111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 01/27/2023] Open
Abstract
Survival and neurological outcomes after out-of-hospital cardiac arrest (OHCA) remain low. The further development of prehospital extracorporeal resuscitation (ECPR) towards Controlled Automated Reperfusion of the Whole Body (CARL) has the potential to improve survival and outcome in these patients. In CARL therapy, pulsatile, high blood-flow reperfusion is performed combined with several modified reperfusion parameters and adjusted defibrillation strategies. We aimed to investigate whether pulsatile, high-flow reperfusion is feasible in refractory OHCA and whether the CARL approach improves heart-rhythm control during ECPR. In a reality-based porcine model of refractory OHCA, 20 pigs underwent prehospital CARL or conventional ECPR. Significantly higher pulsatile blood-flow proved to be feasible, and critical hypotension was consistently prevented via CARL. In the CARL group, spontaneous rhythm conversions were observed using a modified priming solution. Applying potassium-induced secondary cardioplegia proved to be a safe and effective method for sustained rhythm conversion. Moreover, significantly fewer defibrillation attempts were needed, and cardiac arrhythmias were reduced during reperfusion via CARL. Prehospital CARL therapy thus not only proved to be feasible after prolonged OHCA, but it turned out to be superior to conventional ECPR regarding rhythm control.
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Affiliation(s)
- Sam Joé Brixius
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
- Correspondence:
| | - Jan-Steffen Pooth
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Jörg Haberstroh
- Centre for Experimental Models and Transgenic Service, Department of Experimental Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79104 Freiburg, Germany;
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Christian Scherer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Philipp Greiner
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Christoph Benk
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
| | - Georg Trummer
- Department of Cardiovascular Surgery, Faculty of Medicine, University Medical Centre Freiburg, University of Freiburg, 79106 Freiburg, Germany; (J.-S.P.); (D.D.); (C.S.); (P.G.); (C.B.); (F.B.); (G.T.)
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Sanetra K, Domaradzki W, Cisowski M, Białek K, Shrestha R, Bochenek A, Jankowska-Sanetra J, Buszman PP, Gerber W. Age- and gender-related differences in the del Nido cardioprotection protocol. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:502-509. [PMID: 34105925 DOI: 10.23736/s0021-9509.21.11710-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The evidence regarding the impact of patient's age and gender on del Nido cardioplegia cadioprotection capability in adults is strongly limited. METHODS A group of 75 patients undergoing aortic valve replacement (AVR) with del Nido cardioplegia was divided into Group 1 (male) and Group 2 (female). Creatine kinase (CK-MB isoenzyme) and high sensitivity troponin T (hs-TnT) values at 24 hours and 48 hours, occurrence of cardiac activity during crossclamp and ventricular fibrillation (VF) during reperfusion were compared. The impact of age on hs-TnT,CK-MB, VF during reperfusion and cardiac activity during crossclamp was investigated using regression models. RESULTS No difference between the groups was reported in 24-hour CK-MB (median 15.57 ng/ml; IQR 12.13-22.82 ng/mL vs 13.97; 12.09-17.147 ng/mL; p= .168), 48-hour CK-MB (6.19; 4.22-7.71 ng/mL vs 6.07;4.56-7.06 ng/mL; p= .707), 24-hour hs-TnT (259.2; 172.0-376.9 pg/mL vs 193.0; 167.8-351 pg/mL.1; p= .339), 48-hour hs-TnT (169.1; 124.9-293.0 pg/mL vs 159.2; 123.12-211.77 pg/mL; p= .673), VF during reperfusion (25% vs 18,5%; p= .774) and cardiac activity during arrest (39.6% vs 37.1%; p= 1.0). Values of CK-MB at 24 hours, hs-TnT at 24 hours and hs-TnT at 48 hours were not dependent on age. The CK-MB at 48 hours was dependent on age (p=.039). Probit regression failed to reveal the impact of patients' age on post-clamp VF occurrence ( p=.11) or electrical activity during arrest (p=.57) . CONCLUSIONS Basing on study results, it can be hypothesised that the del Nido cardioplegia provides adequate myocardial protection in AVR patients regardless of age and gender.
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Affiliation(s)
- Krzysztof Sanetra
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kakow University, Krakow, Poland - .,Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland -
| | - Wojciech Domaradzki
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland
| | - Marek Cisowski
- Department of Cardiac Surgery, Clinical University Hospital, Opole, Poland
| | - Krzysztof Białek
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland
| | - Rajesh Shrestha
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland
| | - Andrzej Bochenek
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland.,Faculty of Medicine, University of Technology, Katowice, Poland.,Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | | | - Piotr P Buszman
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kakow University, Krakow, Poland.,Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland.,Department of Cardiology, American Heart of Poland, Bielsko-Biała, Poland
| | - Witold Gerber
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, Poland
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Elmahrouk AF, Elghaysha E, Arafat AA, Edrees A, Aluthman U, Jamjoom AA. Bolus potassium in frustrated ventricular fibrillation storm: Evidence are growing! J Card Surg 2020; 35:2117. [PMID: 32652774 DOI: 10.1111/jocs.14732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed F Elmahrouk
- Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.,Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Ehab Elghaysha
- Cardiac Surgery Intensive Care Unit (CSICU) Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.,Intensive Care Unit, Basildon and Thurrock University Hospital, Essex, UK
| | - Amr A Arafat
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Azzahra Edrees
- Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Uthman Aluthman
- Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ahmed A Jamjoom
- Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Chowdhry V. Cardioplegic arrest as pharmacological defibrillation; A novel approach for refractory ventricular fibrillation. Ann Card Anaesth 2020; 23:541-542. [PMID: 33109826 PMCID: PMC7879917 DOI: 10.4103/aca.aca_6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Marill KA, Salcido DD, Sundermann ML, Koller AC, Menegazzi JJ. Energy conserving chemical defibrillation of ventricular fibrillation: A randomized two phase controlled blinded trial. Resuscitation 2016; 103:41-48. [PMID: 27039984 DOI: 10.1016/j.resuscitation.2016.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 03/01/2016] [Accepted: 03/10/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Potassium cardioplegia-induced transient asystole may conserve myocardial energy, foster chemical defribrillation, and improve VF arrest outcome. A trial of potassium infusion with or without calcium reversal was conducted to test for improvement in intra-arrest VF waveform and post-ROSC hemodynamics. METHODS Eighteen swine were randomized to three treatment arms in two phases. VF was electrically induced and untreated for 4min. The animals then received 6min of mechanical CPR. Blinded investigators infused two study medicines peripherally during this interval. One group received 1.5mEq/kg KCl with CPR initiation followed 3min later by CaCl 10% infusion 0.12cm(3)/kg, the second group received 1.5mEq/kg KCl without CaCl, and the third group received placebo infusions. Ten minutes post VF initiation, defibrillation was performed, as appropriate, followed by ACLS for continued arrest or observation for 30min if ROSC. AMSA change from before to 5min post study drug infusion was compared with nonparametric statistics. MAP post ROSC was compared using mixed linear regression analysis. RESULTS Average normalized AMSA change was -0.15, -0.63, and +0.27 in the KCl, KCl+CaCl, and placebo groups, respectively (p=0.01). Three KCl+CaCl animals developed on organized rhythm chemically without electrical defibrillation. One, 3, and 4 animals in the KCl, KCl+CaCl, and placebo groups, respectively, survived post ROSC. Post ROSC, MAP decreased 1.8mmHg (95% CI -1.4 to 5.1) min(-1) less in the KCl+CaCl group compared to placebo. CONCLUSIONS Chemical defibrillation and ROSC are possible post potassium-induced asystole. Potassium followed by calcium reversal, but not potassium alone, led to ROSC and post-ROSC hemodynamics comparable to recommended therapy.
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Affiliation(s)
- Keith A Marill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States.
| | - David D Salcido
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States
| | - Matthew L Sundermann
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States
| | - Allison C Koller
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States
| | - James J Menegazzi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States
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Almdahl SM, Veel T, Eide M, Damstuen J, Halvorsen P, Mølstad P. Postcardioplegia ventricular fibrillation: no impact on subsequent survival. SCAND CARDIOVASC J 2014; 48:249-54. [PMID: 24814392 DOI: 10.3109/14017431.2014.922212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES At aortic declamping after cardioplegic cardiac arrest, the initial rhythm can be broadly classified as ventricular fibrillation (VF) or non-VF. VF can be treated with potassium-induced conversion and direct-current countershock is only applied if potassium treatment fails. We aimed to investigate whether there are any differences between these groups of patients in regard to outcomes. DESIGN From January 1999 through December 2010, 12,113 patients underwent various types of cardiac surgery. Data from every patient were consecutively registered. Survival was established through the Norwegian National Registry. Cox multivariable modeling with adjustment for clinical, biochemical, and medication baseline data was used for survival analysis. RESULTS The mean follow-up time was 7.4 years and total patient-years were 89,268. The percentage of all-cause deaths was 24.9. Adjusted survival for patients with no postcardioplegia VF (n = 9723) and patients with successful potassium-induced conversion (n = 1877) was completely identical. Four hundred patients with electrical conversion after failed potassium treatment had a nonsignificant trend toward an increased mortality (hazard ratio, 95% confidence interval: 1.19 (0.99-1.4); p = 0.07). CONCLUSIONS This is the first study reporting the association between postcardioplegia VF, its treatment with potassium and outcome. No impact was found on outcome as judged by all-cause mortality.
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Kook Lee B, Joon Lee S, Woon Jeung K, Youn Lee H, Jeong IS, Lim V, Hun Jung Y, Heo T, Il Min Y. Effects of potassium/lidocaine-induced cardiac standstill during cardiopulmonary resuscitation in a pig model of prolonged ventricular fibrillation. Acad Emerg Med 2014; 21:392-400. [PMID: 24730401 DOI: 10.1111/acem.12348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 08/20/2013] [Accepted: 11/19/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Several studies in patients who underwent open heart surgery found that myocardial ischemic damage was reduced by potassium cardioplegia combined with lidocaine infusion. The authors evaluated the effects of potassium/lidocaine-induced cardiac standstill during conventional cardiopulmonary resuscitation (CPR) on myocardial injury and left ventricular dysfunction after resuscitation from prolonged ventricular fibrillation (VF) cardiac arrest in a pig model. METHODS Ventricular fibrillation was induced in 16 pigs, and circulatory arrest was maintained for 14 minutes. Animals were then resuscitated by standard CPR. Animals were randomized at the start of CPR to receive 20 mL of saline (control group) or 0.9 mEq/kg potassium chloride and 1.2 mg/kg lidocaine diluted to 20 mL (K-lido group). RESULTS Seven animals in each group achieved return of spontaneous circulation (ROSC; p=1.000). Four of the K-lido group animals (50%) achieved ROSC without countershock. Resuscitated animals in the K-lido group required fewer countershocks (p=0.004), smaller doses of epinephrine (p=0.009), and shorter durations of CPR (p=0.004) than did the control group. The uncorrected troponin-I at 4 hours after ROSC was lower in the K-lido group compared with the control group (2.82 ng/mL, 95% confidence interval [CI]=1.07 to 3.38 ng/mL vs. 6.55 ng/mL, 95% CI=4.84 to 13.30 ng/mL; p=0.025), although the difference was not significant after Bonferroni correction. The magnitude of reduction in left ventricular ejection fraction (LVEF) between baseline and 1 hour after ROSC was significantly lower in the K-lido group (26.5%, SD±6.1% vs. 39.1%, SD±6.8%; p=0.004). CONCLUSIONS In a pig model of untreated VF cardiac arrest for 14 minutes, resuscitation with potassium/lidocaine-induced cardiac standstill during conventional CPR tended to reduce myocardial injury and decreased the severity of postresuscitation myocardial dysfunction significantly.
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Affiliation(s)
- Byung Kook Lee
- The Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Republic of Korea
| | - Seung Joon Lee
- The Department of Emergency Medicine; Myongji Hospital; Goyang Republic of Korea
| | - Kyung Woon Jeung
- The Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Republic of Korea
| | - Hyoung Youn Lee
- The Department of Emergency Medicine; KS Hospital; Gwangju Republic of Korea
| | - In Seok Jeong
- The Department of Thoracic and Cardiovascular Surgery; Chonnam National University Hospital; Gwangju Republic of Korea
| | - Victor Lim
- The Centre of Hepatobilliary Surgery of Uzbekistan; Republican Clinical Hospital No. 1 of the Ministry of Health of the Republic of Uzbekistan; Tashkent Uzbekistan
| | - Yong Hun Jung
- The Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Republic of Korea
| | - Tag Heo
- The Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Republic of Korea
| | - Yong Il Min
- The Department of Emergency Medicine; Chonnam National University Hospital; Gwangju Republic of Korea
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